Institute of Obstetrics and Gynecology

PREGNANCY WITH ADVANCED SEROUS OVARIAN CARCINOMA – SUCCESSFUL FETO-MATERNAL OUTCOME

• 29 year old Prmigravida, Mrs.X 20 weeks of gestation, was referred to tertiary centre for management of ovarian cyst complicating pregnancy. USG showed multi-loculated cyst with septations in left ovary. Lesion was found to be progressively increasing in size. MRI done which revealed T2 hyperintense lesion of size 6.75x6cms with multiple septations in the left ovary. Tumor markers were done and found to be raised. CA-125- 671.

• Surgical oncologist and medical oncologist opinion was obtained and uterus sparing staging laparotomy was done in mid-trimester at 24weeks. Pathological results revealed Micro-papillary variant of serous carcinoma – invasive type with omental deposits. – STAGE III A. Post operatively patient was given 4 cycles of chemotherapy antenatally. (Carboplatin x 2 cycles and Carboplatin with cyclophosphamide x 2 cycles). Elective LSCS along with Right salpingo-ophrectomy was done at 38weeks. After LSCS patient received 2 cycles of Chemotherapy. Patient is now under regular follow up in medical oncology with no recurrence. Mother and baby are healthy.

LIMB GRIDLE MUSCULAR DYSTROPHY COMPLICATING PREGNENCY

• A 33 years old primi Ms-1Year 147 cm/LMP 23.8.20 EDD 30.5.2021 presented in AN opd with single intra uterine gestation of 35w+6 days.

• History of viral illness 6-7 years back followed by weakness of lower limbs with difficulty in walking/squatting position/combing hair/buttoning dress H/o of sibling who died of muscular dystrophy (respiratory depression) Patient had tested Covid positive Primary cesarean section done, Boy baby. Weight – 2.6 kg. Post partum, Mother and baby was healthy.

SEVERE PULMONARY HYPERTENSION COMLICATING PREGNANCY

A Case of 28years old, G2P1L1, Previous one LSCS presented at 32 weeks with complaints of breathlessness for one month, aggrevates on walking for few steps, (NYHA – 111). Admitted in ICU, Echo done and was found to have severe Pulmonary Hypertension (TRPG-72mmHg). Rheumatology opinion obtained, found to have connective tissue disorder – Anti-SS-A and Anti-SS-B Positive. Patient was started on diuretics, Vasodilators(T.Sildenafil), HCQ, Steroids and MgSO4 for neuroprotection. Emergency LSCS done with Cardiologist standby under general anaesthesia at 32weeks + 4 days. Intra-op and Post-op period was uneventful. Post operatively cardiologist opinion obtained and T.Bosentan was started. Appropriate treatment with Multi-disciplinary approach at right time had saved mother’s life. Now she is in regular cardioilogy follow up. Alive and healthy. T.Bosentan 10 tablets costs 800 rupees. But this all medications was given free of cost in IOG and RGGGH.

RETROPERITONEAL TERATOMA IN PREGNANT WOMEN-RARE PRESENTATION – SUCCESSFUL FETOMATERNAL OUTCOME

Retroperitoneal tumours originating from retroperitoneum without originating from major organs are rare. 70-80% of the primary retro-peritoneal tumours are malignant. Most common malignant tumours in this region are sarcomas. Most common benign lesion is lipoma and fibromas.

• CASE REPORT:26 years old G2P1L1, 15weeks 5 days gestational age came to OPD with incidental finding of dermoid cyst. Routine antenatal screening and MRI showed mass of size 29x17x11.8cms well defined abdominopelvic lesion with cystic and solid areas – probably dermoid cyst. Tumour markers were within normal limits.
• MANAGEMENT:Elective Laprotomy done at 17weeks of Gestation. Large mass 20x10cms displacing left ureter and kidney posteriorly, not infiltrating any vital organs. Mass resected and sent for biopsy – HPE revealed benign mature teratoma showing long bones with marrow material – possibility of fetiform teratoma. Patient came for routine antenatal checkups. Delivered by labour natural at term with no intra-partum and post-partum complications. USG done after 6 months – no significant abnormality.

1st CASE OF NEONATAL ALLO-IMMUNE THROMBOCYTOPENIA – GOOD FETO-MATERNAL OUTCOME

• A case of BOH, booked and immunized at GG Pettai. previous baby died at 21 days on March 2022.The patient and the baby was referred to ICH for intracranial hemorrhage in march 2022 from chengalpattu medical college and the baby was evaluated in ICH for human placental antigen genotyping and HPA 3b and HPA 15b incompatability detected between the mother and baby and so this patient was advised to review at pediatric ICH hematology department for next pregnancy in march 2022.
• So in this pregnancy,on 4.7.23, at 15weeks of Gestational age, patient referred from chengalpattu medical college to pediatric hematology department ICH and IOG for further mangament.
• From pediatric department ICH, patient was discussed with Dr. Bipin kulkarni, NIIH, mumbai.
• Patient was advised to give immunoglubulins 30gram/week till delivery.As per hematologist opinion, patient was admitted and intravenous immunoglobulin (IVIGs)was planned weekly once.
• Initially IV IGs Obtained from guindy since cost of IVIGs high
• 1. 1st dose given On 4.8.23(6 vials)
  2. 2nd dose given on 11.8.23(6 vials)
  3. 3rd dose given on 25.8.23(6 vials)
• Totally 18 vials given for the patient.12 vials purchased from TNMSC 6Vials from RGGGH Since IVIGS stock was exhausted in our hospital. NHM director was approached by Director of Institute. NHM accepted to issue the fund under operational cost for purchasing IVIGS. So totally 66vials(11doses given)
• Immunoglobulin were started weekly once upto 34weeks.On 14.11.23 patient admitted with draining pv, so inview of Prev lscs in labour emegency caesearean section was done. She delivered a preterm girl baby of weight 2.47kg on 14.11.23@8:02am So totally an amount of RS 3,34,416 was spent for this patient through our CMCHIS fund for preventing the transmission of neonatal alloimmune thrombocytopenia for the baby. This is the first case of neonatal alloimmune thrombocytopenia delivered at IOG. We are proud to have the first case. The mother and the baby doing fine now.

OHVIRA SYNDROME

• A 14 year old came with c/o reduced menstrual flow for past 2 years Associated with lower abdominal pain. Patient evaluated. Ultrasound report- right renal agenesis with obstructed hemi vagina causing right sided hematometrocolpos - suggestive pf Herlyn Werner Wunderlich syndrome/OHVIRA syndrome
• MRI pelvis finding- Uterus didelphys with right hematocollis, obstructed hemi vagina and absent right kidney in right renal fossa. Patient was assessed and planned for laparoscopy assisted hematocollis drainage. After drainage patient on follow up on op basis Post op USG shows no evidence of collection in uterine cavities, no free fluid abdomen. Patient is symptomatically better now

SUCCESS STORY 7

• We have done the first case of Laparoscopic Cesarean scar ectopic excision and repair at Institute of Obstetrics and Gynecology, Egmore.
• She is a 36 yr old G2P1L1, with previous Cesarean section, with 8 weeks gestation at the cesarean scar site. beta hcg - 63000. This Scar ectopic is very rare presentation. Laproscopic excision has reduced morbidity and period of hospital stay.

CARCINOSARCOMA OF OVARY

• Diagnosis: Carcinosarcoma of ovary (Incidence: 1.12%) – Rare case
• Patient: 43 years old, P2L2
• Chief Complaint: Abdominal pain, more on the right side
• Investigations:
  • CA-125: 147
  • USG (21/09/2023): Right complex ovarian cyst with internal septations and solid component
  • CECT Abdomen (23/09/2023): Right adnexal malignant lesion (11x12.5 cm), likely of right ovarian origin
• Procedure: Staging laparotomy followed by:
  • TAH (Total Abdominal Hysterectomy)
  • BSO (Bilateral Salpingo-Oophorectomy)
  • Infra-colic omentectomy
  • Bilateral pelvic lymph node dissection
  • Specimens sent for HPE
• Intra-operative Findings:
  • Right adnexal cyst – 15x12 cm, adherent to anterior uterine wall and bladder
  • Right fallopian tube – stretched out
  • Uterus size – 8–10 weeks
• Transfusions:
  • Intra-op: 1 unit PRBC
  • Post-op: 3 units PRBC
• HPE Report: Carcinosarcoma – Homologous type
• FIGO Stage: 1C
• Markers: HER2 (IHC) done – reports awaited
• Plan: Start Trastuzumab if HER2 positive

FERTILITY SPARING TREATMENT FOR ENDOMETRIAL CARCINOMA

• Patient: 27 years old, Nulligravida, MS 1½ years
• Reason for Admission: AUB-E (Abnormal Uterine Bleeding – Endometrial) for evaluation
• Biopsy (18/10/2023): Hysteroscopy-guided biopsy showed Endometrioid endometrial adenocarcinoma, Grade 1
• Ultrasound (USG):
  • Endometrial hyperplasia – 2.7 cm
  • Complex cystic degeneration noted in endometrial cavity
• MRI Pelvis (06/10/2023):
  • Stage 1A carcinoma endometrium
  • Bilateral PCOS (Plain with contrast)
• Treatment:
  • Mirena (Levonorgestrel IUD) inserted
  • Tablet Megestrol 160 mg once daily (0-0-1)
• Follow-up: Patient on medical management and regular follow-up

GANGLIONEUROMA – RARE CASE PRESENTATION

• Patient: 12 years old child
• Chief Complaints:
  • Lower abdominal pain – 2–3 months
  • Abdominal distension – 1 month
• On Examination (P/A):
  • Abdomen distended
  • Tenderness present in right hypogastric region
  • Large mass occupying right hypogastric region
• MRI Findings:
  • 9.1 x 7.2 x 8.2 cm well-lobulated cystic lesion in right adnexa
  • Right ovary not visualized separately
  • Likely benign complete right ovarian cystic lesion – ? Cystadenoma
• Procedure: Diagnostic laparoscopy followed by laparotomy with right cystectomy
• Intra-operative Findings:
  • Infantile uterus
  • Two cysts: 8x8 cm and 6x7 cm in retroperitoneum, adherent to each other
  • Right ureter lateralised
  • Cysts removed preserving the right ovary
• Histopathology (HPE): Lesion revealed as Ganglioneuroma
• Current Status: Patient on follow-up

ENDOMETRIAL STROMAL CELL CARCINOMA